Wednesday, 9 April 2008

I’m back, at long last, my broadband is up and (semi)functional again. A lot’s happened in the three weeks or so that I’ve been offline but one situation a found myself in when I was on call that particularly sticks in my mind.

A lot is written about doctors “playing God” and being arrogant enough to believe that they can decide who should live or who should die. As always, the real truth is somewhat more complicated so let me tell you the story of me and Mr Johnstone.

It’s about 10am on a Sunday and I’m on call for anaesthetics in NewTown Hospital. I’m doing a little studying on one of the computers in the staff room when my pager goes off. It’s one of the surgical registrars who tells me that they want to operate on a Mr Johnstone on Ward 4B who has bowel obstruction. I ask her a couple of questions about the patient and it’s immediately apparent that this isn’t going to be a straight-forward situation.

I logoff and go to the ward where I bump into Mr De Luca, the consultant surgeon on-call, who tells me that he thinks the obstruction in Mr Johnstone’s bowel is most likely to be cancerous but that he is too frail to perform major surgery on. Mr De Luca’s plan is to perform a small operation to create a colostomy for Mr Johnstone which would prevent his bowel from bursting, which would be fatal for him. Mr De Luca asks if we could do the operation under spinal anaesthetic i.e. an injection in the back to numb the nerves so the operation can be done with Mr Johnstone awake.

I tell Mr De Luca that I’ll go and speak to Mr Johnstone and then we’ll discuss things more, he says “Fine, go ahead.”

I pick up Mr Johnstone’s hefty medical notes and walk into the bay where he is lying. He’s all skin and bones and has the emaciated look of a man that has obviously been unwell for a very long time. Mr Johnstone’s belly is grossly swollen (a sign of his underlying intestinal obstruction) and thin, blue veins meander across his belly. His paper-thin skin gives it the look of a balloon filled with water. There is a drip attached to his arm that is trickling fluids into his bloodstream and out of his nose emerges a naso-gastric tube connected to a bag by his bed that is filled with green, bilious vomit. There is a smell of stale sweat and puke around his bedside and you don’t need to be medically qualified to tell that Mr Johnstone is a very unwell man indeed.

“Good Morning Mr Johnstone,” I say as I approach his bed.

His eyes flicker open as he regards me approaching him. I give him a small smile.

“My name is Dr Anderson,” I continue. “I’m the anaesthetic doctor and the surgeons have asked me to come and see you because you need an operation on your belly. How are you feeling?” It’s a stupid question, I know. “You’ve had better days, yeah?”

Mr Johnstone and I speak for about twenty minutes or so about his current illness and about his general health.

I won’t go into too many details but from speaking to Mr Johnstone and reading his medical notes, I found out that he has severe heart, lung and kidney problems. The last six months of his life have been studded with hospital admissions for chest infections and heart attacks. When he is at his very best, he can only manage to walk a dozen steps after being helped up from the chair, but Mr Johnstone hasn’t been at his best since October. He’s been getting steadily worse and has been bed-bound for the last two months.

It was obvious to me that Mr Johnstone was so frail that if I gave him any sort of anaesthetic, he wouldn’t survive. The question now was whether a more experienced anaesthetist would feel that he would be able to safely guide Mr Johnsotone through the surgery.

I call Dr Adams, the consultant anaesthetist on-call and explain the situation to him and ask him to come and help with this patient. One of the great things about working in anaesthetics as opposed to other medical specialties is that if you feel you need help from your consultants, they come in and help you. They don’t have a go at you and tell you to “get on with it, just make sure you don’t fuck up.”

Half an hour later, Dr Adams and spoken to and examined Mr Johnstone and poring over his medical notes, scratching his beard (literally) as he tussles with the question that I’ve asked him to answer. “Can I give Mr Johnstone an anaesthetic, and if so how?”

Dr Adam’s brow is furrowed and you can almost see his mind working. After about ten minutes of deliberation, he comes to a decision…

“No.” He says to me. “We can’t do it. I’ve been weighing up all the different options and scenarios in my head. I’ve been thinking of all the things that are likely to happen to him if he has an operation and I can’t see a situation where he will have a decent outcome.

“I agree with you Michael, that he’s far too frail to have a general anaesthetic and he’ll die on us if we try to give him one. That leaves us with the option of giving him a spinal (the injection into the back) and I’ve been going through what the best-case scenario is likely to be.

“Best-case: We get him down to theatres, and we actually manage to get the spinal needle in. For a colostomy, he’s going to need quite a high block – up to about T7-8. He had a heart attack a couple of months ago, and his echocardiogram shows his heart has been knackered since 2002, so the chances are his heart won’t cope with the drop in blood pressure that you get with a spinal anaesthetic. Even if we manage to achieve that and the block works well, and even if we manage to lie him flat enough to have the operation and even if the surgeons are quick and slick and aren’t digging around for ages, what’s going to happen next?

He’s going to come back to the ward and in six hours time, the spinal will wear off and then he’ll be in pain. He won’t breathe properly because he’s in pain and then, with his lungs, he’ll get a chest infection and die. Or someone will come along and give him some morphine which will stop him breathing properly and then he’ll get a chest infection and die.

So, in the very best case scenario, he has his operation, is semi-conscious for 12 hours post-op before dying here a week later, and you’ve got to ask ‘have we done him any favours?’”

We go and explain our decision to Mr Johnstone and then to the surgeons. Mr Johnstone understood that he needed the operation to save his life and was very upset when we told him he couldn’t have it. Later in the afternoon I return to the ward to explain the decision to Mr Johnstone’s daughters and other relatives who are understandably very upset by the whole situation.

Later on, I had a quiet moment and thought about the events of the morning. Unless a miracle happens, Mr Johnstone’s bowels will burst and then he’ll die. Over the preceding day or so, he was told that there was an operation that could prevent this and he was given hope. Then we snatched away any hope he had by telling him he was told that he couldn’t have the operation. This was cruel, horribly, horribly cruel.

I can’t put myself in the shoes of Mr Johnstone or his family, his final days will probably be difficult, painful and horrible. But death is often difficult, painful and horrible and unfortunately for Mr Johnstone, this time we can’t stop him dying.

I don’t really think that this is “playing God,” I think it’s accepting the fact that death is an inevitability that we all have to face and that doctors can’t save everyone from dying, no matter how much we’d like to.

What do you readers think about what happened with Mr Johnstone?

n.b. Interestingly, when I talked about this is the doctor’s mess later on, two surgical SHOs, the surgical SpR and the Medical SpR initially all said that they thought that Mr Johnstone should have had the operation. Personally, I think this just shows a lack of understanding about how anaesthesia works and all apart from the Medical SpR reversed their opinions when I explained the effects of spinal anaesthesia on the cardiovascular system.

12 comments:

I think the what happened was the right thing. Obviously such a decision should never be taken lightly, and by the sounds of it, a lot of thought was put into it. It is such a difficult situation, especially as the patient and relatives are unlikely to understand all the details of the anaesthetic etc etc.

It sounds like a difficult situation. Perhaps it might have been helped if Mr Johnstone's first message wasn't 'You need surgery and then you'll be fine,' but rather 'We'd like to operate if we can, but we need to investigate the ramifications.' That might have set his (and his family's) expectations a little more in line with reality.

Having said that though, I think what you did makes perfect sense. If it can't be done safely, it can't be done. It's unfortunate that the man was looking at dying a lot faster than he'd anticipated, but he must have known his body was shutting down in various ways. Sometimes it's just done as much as it can handle, don't you think?

Wow - a dilemma that I would never like to have to face. It doesn't sound like there was much of a choice; at the most a successful operation could give him a week more. (and if the predicted chest infection did the same thing to him that it did to my grandfather, then it isn't exactly a week of life)

Michael I think both you and your cosultant acted appropriately and in Mr. Johnstone's best interest.

As a medical SHO, I'm constantly dealing with situations on call where patients who have been doing very badly for a while have no idea from their primary team how ill they are. No discussion with the patient about how high the ceiling of care should be or what would be appropriate in the event of an arrest. Maybe it's the medico legal culture we work in but when it comes to elderly patients and those with multiple medical comorbidities I think we are failing in our duty as physicians to alleviate suffering by constantly pushing for another surgery, another intubation, another chance in ICU. Everyone has their time, and when we as doctors can see that that time is clearly at hand we should be discussing the prognosis more frankly with patients.

Points of interest from your post:

1. Fantastic consultant back up in Anaesthesia. Needless to say, I wouldn't have the same back up in Internal Medicine.

2. Intersting discussion of the physiology of a spinal block; I'd never stopped to consider the cardiovascular implications of same.

3. Hospital At Night has cut the number of docs on call dramatically yet the Anaesthetics SHO, surgical SHO and SpR and Medical SpR all have time to chat in the Res? Things aren't as bad across the pond as I thought! :D

Thanks for the welcome back, it's amazing how much more difficult life is without access to the internet.

TLM - when I was speaking to the relatives, I tried to make them see what the likely outcomes were with and without the operation, I'm not sure how much of what I was saying they took on board though, there were (understandably) lots of tears

Anon1 - I think you're right and it woul have been better had the consultant surgeon and anaesthetist involved spoken about this before telling the family. I suppose these things are made more difficult by there being different surgical and anaesthetic consultants on call on different days of the week. Patient continuity will ultimately suffer.

Tazocin - As a former medical SHO myself, I've been in those situations too many times and can well empathise with what you say.

1 - Consultant anaesthetists are really supportive of their juniors, much more so than in any other acute specialty IMO

2 - More and more I realise that other specialties have little idea what anaesthesia involves. I think that the "relaxed" demeanor of a lot of anaesthetist gives the impression that there's not much to it and the low complication rates of anaesthetics gives the impression that not much can go wrong. Both are fallacies and I'll blog more about this another time

3 - Yeah, point taken. There were no surgical emergencies at that point in the afternoon, so me and the surgical team went to have a coffee in the mess where we found the Med Reg having lunch. I wouldn't say this was a common situation though!

I think you did the right thing. I also agree that a bit of communication between teams would have helped the patient and the family.

I can think of more than one occasion where a surgeon has been drumming his heels waiting for the anaesthetist to see the patient then being horrified when the case was cancelled. If a patient isn't well enough then you just don't go ahead. Patient welfare comes first. Not only that the cynic in me thinks that if anything went wrong and the family (I'm not talking about your example now) wanted to sue the surgeon would probably say, "Well now, had the anaesthetist told me the patient was too sick of COURSE I wouldn't have pressured them to do the case." Or maybe that's just my experience of a couple of surgeons!

Sometimes we can't make it all better. Sometimes we have to let people go. You did the right thing.

I'm reminded of the joke. A good man dies and goes up to heaven and meets St Peter at the pearly gates. "Come in" St Peter says "You have been a good man" and he goes in to heaven. "I will come and see you later" says St Peter and the man goes in and sits on his own cloud and plays on his harp.

St Peter returns later and asks "How are you settling in?" "Fine" says the good man. "I do have one question, however", says the man "there is an old bloke who is wandering around, with a stethoscope around his neck - who is he?"

St Peter replies "Oh, that's God; he like playing at being a doctor".

Good, thoughtful and caring blog. These are the kind of issues that, from time to time, we face in General Practice. For what it is worth, I think the anaesthetic decision is the caring decision.

Working in ICU, I used to see the flip side to this all the time - people being barely kept alive and flogged on like that for days or weeks on end, until someone had the guts to say enough is enough. If only it had been said earlier, even before admission to ICU, lots of painful memories for families and friends would have been saved.

You and I know that your patient's situation was hopeless. Had you operated and by some miracle he hadn't died on the table, he'd havee ended up in ICU, where the family would have got their hopes up only to have them dashed in a couple of weeks, after a traumatic experience for all concerned. This way he gets to go relatively peacefully and say goodbye to everybody. I know which I'd choose!

i don't want to sound like a pointless critic but surely you could have explained the situation to the patient and let him decide for himself. it's fair doos that it's tough to give reliable numbers on risk and that it's hard to understand risk but if the patient could give a history then maybe it's worth letting him decide if he wanted to go on full stream ahead or take the quiet way out...

To anonymous re patient choice - unless the patient has watched a very unwell person undergo nigh fatal surgery only to stay in ICU for weeks/months struggling from crisis to crisis can they truly experience informed choice.

I think the descision you made was the right one for the gentlemans dignity and allowed he and his family to be aware of what was happening however unpleasant the reality is. I am a palliative care nurse working in a hospice and sometimes people are referred to us too late for us to be able to make their last weeks/days good ones, surgeons have just hung on too long before admitting that it's time to stand back and let palliative care do it's job....keeping them as symptom free as possible and enjoying time with their family.I have learnt so much since I changed to this type of work.